本文選題：目標(biāo)導(dǎo)向 + 液體治療��； 參考：《浙江大學(xué)》2014年博士論文

【摘要】：第一部分 目標(biāo)導(dǎo)向液體治療在腹腔鏡肝臟切除中的臨床對(duì)比研究 研究目的通過對(duì)目標(biāo)導(dǎo)向液體治療和常規(guī)液體治療在腹腔鏡肝臟切除中的前瞻性臨床對(duì)比研究,評(píng)價(jià)目標(biāo)導(dǎo)向液體治療在腹腔鏡肝臟切除中的應(yīng)用價(jià)值。 研究方法本研究采用病例對(duì)照研究方法,選取2012年1月至2013年7月期間在某醫(yī)院微創(chuàng)中心行腹腔鏡肝臟切除手術(shù)患者47例,以電腦軟件隨機(jī)分組法納入目標(biāo)導(dǎo)向組(GDT)23例,根據(jù)Flotrac/vigileo系統(tǒng)監(jiān)測(cè)維持心指數(shù)2.5～4L/minxm2且每搏變異度13%；常規(guī)治療組(CVP)24例,維持中心靜脈壓5-12mmHg且平均動(dòng)脈壓65-90mmHg。所有病例都由同一治療組固定成員完成手術(shù)操作,均采用相同的全身麻醉方案,比較兩組患者的手術(shù)時(shí)間、氣腹時(shí)間、切肝時(shí)間、補(bǔ)液總量、出血量、術(shù)中尿量、輸血量、有創(chuàng)動(dòng)脈血壓、心率及血?dú)獗O(jiān)測(cè)結(jié)果術(shù)中指標(biāo),術(shù)后氣管導(dǎo)管拔除時(shí)間、肛門排氣時(shí)間、進(jìn)食時(shí)間、下床活動(dòng)時(shí)間、術(shù)后3天內(nèi)的鎮(zhèn)痛情況、有無并發(fā)癥、術(shù)后住院日及住院費(fèi)用、術(shù)后7天內(nèi)生命體征和腹腔引流量等臨床指標(biāo),以及血常規(guī)、肝腎功能和凝血功能的實(shí)驗(yàn)室指標(biāo)。 結(jié)果3例因術(shù)中中轉(zhuǎn)開腹排除本研究,最終完成研究共44例,其中GDT組21例,CVP組23例。兩組在年齡、性別、體重指數(shù)、ASA分級(jí)、Child分級(jí)、疾病種類以及術(shù)式上無統(tǒng)計(jì)學(xué)差異(P0.05)。兩組比較,在二氧化碳?xì)飧箷r(shí)間、手術(shù)時(shí)間、切肝時(shí)間、出血量、術(shù)中尿量、輸注晶體液總量以及術(shù)中輸注紅細(xì)胞比例上無統(tǒng)計(jì)學(xué)差異(P0.05),但GDT組術(shù)中輸注膠體液總量少于CVP組(P0.05),具有統(tǒng)計(jì)學(xué)差異。術(shù)中兩組之間的動(dòng)脈平均壓、心率、指脈搏氧飽和度、呼氣末二氧化碳無統(tǒng)計(jì)學(xué)差異(P0.05),切肝期間GDT組的PH值高于CVP組(P0.05),建立氣腹并頭高位時(shí)GDT組BE值高于CVP組(P0.05),二氧化碳?xì)飧惯^程中GDT組的動(dòng)脈氧分壓高于CVP組(P0.05)。兩組病人的Hb、Hct、Lac無統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后GDT組氣管導(dǎo)管拔除明顯早于CVP組(P0.01),GDT組肛門排氣早于CVP組(P0.05),GDT組住院費(fèi)用較少(P0.05),具有統(tǒng)計(jì)學(xué)差異。但兩組在進(jìn)食時(shí)間、離床活動(dòng)時(shí)間、術(shù)后住院日及并發(fā)癥發(fā)生率沒有統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后第三天起GDT組腹腔引I流量少于于CVP組(P0.05),術(shù)后5天和術(shù)后7天則顯著低于CVP組(P0.01)。但日平均最高體溫、心率和鎮(zhèn)痛情況兩組之間無統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后3天時(shí)GDT組WBC低于CVP組,術(shù)后5天GDT組的Hb高于CVP組(P0.05)。術(shù)后5天CVP組的APTT長(zhǎng)于GDT組,術(shù)后7天GDT組纖維蛋白原高于CVP組,具有統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后3天、5天、7天GDT組的ALT低于CVP組(P0.05),術(shù)后5天GDT組的AST也低于CVP組(P0.05)。其余實(shí)驗(yàn)室指標(biāo)兩組之間無統(tǒng)計(jì)學(xué)差異(P0.05)。 結(jié)論與常規(guī)液體治療相比,腹腔鏡肝臟切除病人在目標(biāo)導(dǎo)向液體治療下需要輸注的膠體液更少,組織微循環(huán)及氧供更好,肝功能和凝血影響更小,炎癥反應(yīng)更輕,腸道功能恢復(fù)更早,在短期臨床預(yù)后中具有優(yōu)勢(shì),還能明顯減少住院費(fèi)用。 第二部分 目標(biāo)導(dǎo)向液體治療對(duì)腹腔鏡肝臟切除患者應(yīng)激反應(yīng)的影響 研究目的比較目標(biāo)導(dǎo)向液體治療和常規(guī)液體治療對(duì)腹腔鏡肝臟切除患者應(yīng)激反應(yīng)的影響。 研究方法將2012年1月至2013年7月在某醫(yī)院微創(chuàng)中心行腹腔鏡肝臟切除術(shù)的最終入選患者44例,具體分組情況、麻醉及手術(shù)過程詳見第一部分。比較兩組患者手術(shù)前后外周靜脈血中白細(xì)胞總數(shù)及中性粒細(xì)胞百分?jǐn)?shù)以及IL-6、IL-10、 TNF-α等細(xì)胞因子和HSP70、SAA和CRP等急性反應(yīng)蛋白的變化,并比較兩組可的松、胰島素、血糖及胰島素抵抗指數(shù)(HI)的差異以及術(shù)后7天內(nèi)SIRS發(fā)生的情況。 結(jié)果術(shù)前兩組之間可的松、胰島素、血糖和HI無統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后3小時(shí)和12小時(shí)GDT組的可的松水平顯著低于CVP組(P0.01)。術(shù)后12小時(shí)、術(shù)后1天、3天GDT組的血糖和胰島素水平均低于CVP組(P0.05)。術(shù)后3天內(nèi)GDT組HI低于CVP組(P0.05),其中術(shù)后12小時(shí)和術(shù)后3天兩個(gè)時(shí)間點(diǎn)有顯著統(tǒng)計(jì)學(xué)差異(P0.01)。術(shù)后1天發(fā)生SIRS比例最高,GDT組發(fā)生率(42.86%)低于CVP組發(fā)生率(73.91%),兩組之間存在統(tǒng)計(jì)學(xué)差異(P0.05),其余時(shí)間點(diǎn)兩組之間隨無統(tǒng)計(jì)學(xué)差異。術(shù)前兩組之間各細(xì)胞因子和急性反應(yīng)蛋白均無統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后12小時(shí)、術(shù)后1天、3天GDT組IL-6水平低于CVP組(P0.05),術(shù)后5天、7天GDT組IL-6水平明顯低于CVP組(P0.01)。GDT組與CVP組之間進(jìn)行比較,除了術(shù)后5天這個(gè)時(shí)間點(diǎn)之外,術(shù)后所有其他時(shí)間點(diǎn)GDT組的IL-10水平均高于CVP組(P0.05)。術(shù)后12小時(shí)、術(shù)后1天、3天、7天GDT組的TNF-α水平低于CVP組(P0.05)。GDT組術(shù)后12小時(shí)、術(shù)后1天、術(shù)后3天的HSP70水平低于CVP組(P0.05),術(shù)后3天內(nèi)各時(shí)間點(diǎn)GDT組的SAA水平均低于CVP組(P0.05),術(shù)后12小時(shí)和術(shù)后1天GDT組的CRP水平低于CVP組(P0.05)。 結(jié)論與常規(guī)液體治療相比,腹腔鏡肝臟切除病人采用GDT液體治療能降低應(yīng)激相關(guān)激素的水平和胰島素抵抗程度,也能在一定程度上降低術(shù)后炎性細(xì)胞因子和急性期反應(yīng)蛋白水平,降低術(shù)后SIRS發(fā)生率,表明GDT液體治療有助于減輕術(shù)后機(jī)體的炎癥應(yīng)激反應(yīng)程度,加快機(jī)體從應(yīng)激狀態(tài)中恢復(fù)。 第三部分 目標(biāo)導(dǎo)向液體治療對(duì)腹腔鏡肝臟切除患者免疫功能的影響 研究目的比較目標(biāo)導(dǎo)向液體治療和常規(guī)液體治療對(duì)腹腔鏡肝臟切除患者免疫功能的影響。 研究方法將2012年1月至2013年7月在某醫(yī)院微創(chuàng)中心行腹腔鏡肝臟切除的最終入選患者44例,具體分組情況、麻醉及手術(shù)過程詳見第一部分。比較術(shù)后1、3、5、7天兩組患者外周靜脈血T淋巴細(xì)胞CD3、CD4、CD8以及單核細(xì)胞CD14、HLA-DR表達(dá)水平、NK細(xì)胞比例以及IgA、IgM、IgG、C3及C4水平。 結(jié)果GDT組與CVP組比較各時(shí)間點(diǎn)CD3+T淋巴細(xì)胞表達(dá)無統(tǒng)計(jì)學(xué)差異(P0.05)。GDT組與CVP組之間比較,術(shù)前CD4+T淋巴細(xì)胞表達(dá)、CD4+/CD8+T淋巴細(xì)胞比例以及NK細(xì)胞比例均無統(tǒng)計(jì)學(xué)差異。術(shù)后各時(shí)間點(diǎn)GDT組CD4+T淋巴細(xì)胞表達(dá)以及CD4+/CD8+T淋巴細(xì)胞比例均高于CVP組(P0.05)。術(shù)后5天、7天GDT組的NK淋巴細(xì)胞比例高于CVP組(P0.05),術(shù)后3天、5天、7天GDT組的單核細(xì)胞CD14+/HLA-DR+表達(dá)均高于CVP組(P0.05)。GDT組與CVP組相比,術(shù)前外周血IgA、IgG/IgG/C3、C4兩組之間均無統(tǒng)計(jì)學(xué)差異(P0.05)。GDT組在術(shù)后3天IgA的表達(dá)高于CVP組(P0.05),術(shù)后1天及術(shù)后3天GDT組的IgM和IgG表達(dá)均高于CVP組(P0.05),術(shù)后1天GDT組的C4水平高于CVP組(P0.05)。 結(jié)論腹腔鏡肝臟切除病人術(shù)后早期表現(xiàn)為輕度免疫抑制狀態(tài),術(shù)后早期GDT組免疫細(xì)胞比例和免疫球蛋白水平總體上高于CVP組,免疫球蛋白消耗更少,提示GDT組細(xì)胞免疫功能恢復(fù)比CVP組更快更早,對(duì)體液免疫功能的影響更少,GDT液體治療策略較傳統(tǒng)液體治療策略對(duì)術(shù)后免疫功能具有更好的保護(hù)作用。
[Abstract]:Part one
Clinical comparative study of target directed fluid therapy in laparoscopic hepatectomy
Objective to evaluate the value of objective guided liquid therapy in laparoscopic hepatectomy through prospective clinical comparative study of target oriented liquid therapy and conventional liquid therapy in laparoscopic hepatectomy.
In this study, a case control study was used to select 47 cases of laparoscopic hepatectomy from January 2012 to July 2013 in a minimally invasive center of a hospital, and 23 cases were included in the target group (GDT) by the computer software random grouping method. The cardiac index was monitored by the Flotrac/vigileo system, and the cardiac index was 2.5 to 4L/minxm2 and each stroke diversity was 1. 3%, 24 cases in the routine treatment group (CVP), maintaining central venous pressure of 5-12mmHg and average arterial pressure in all cases were performed by the same group of fixed members. The same general anesthesia scheme was used to compare the operation time, pneumoperitoneum time, liver cutting time, total amount of fluid, amount of bleeding, urine volume, blood transfusion in the two groups. Arterial blood pressure, heart rate and blood gas monitoring results, postoperative endotracheal tube extraction time, anus exhaust time, feeding time, ambulation time, 3 days of postoperative analgesia, postoperative hospitalization days and hospitalization expenses, clinical indicators of life body and abdominal volume within 7 days after operation, blood routine and liver and kidney work. Laboratory indicators of energy and coagulation function.
Results 3 cases were excluded because of the operation during the operation, and 44 cases were completed, including 21 cases in group GDT and 23 cases in group CVP. The two groups were in age, sex, body mass index, ASA classification, Child classification, disease types, and no statistical difference (P0.05). The two groups were compared in groups of carbon dioxide pneumoperitoneum, operation time, liver cutting time, bleeding volume, and operation. There was no significant difference in the amount of urine, the amount of the infusion of crystal liquid and the proportion of the infusion of red blood cells (P0.05), but the total amount of the infusion colloid in the group GDT was less than that of the CVP group (P0.05), with statistical difference. The mean arterial pressure, heart rate, pulse oxygen saturation, and no statistical difference between the two groups during the operation were not statistically different (P0.05), and the GDT group during the liver resection period The pH value of the GDT group was higher than that of the CVP group (P0.05), and the BE value of group GDT was higher than that of group CVP (P0.05). The arterial oxygen partial pressure in group GDT in the process of carbon dioxide pneumoperitoneum was higher than that of group CVP (P0.05). There was no statistical difference between the two groups of patients' Hb, Hct, and the extraction of the tracheal conduit was earlier than that of the group. 5), in group GDT, the cost of hospitalization was less (P0.05), but there was statistical difference. But there was no statistical difference between the two groups at the time of feeding, the time of leaving the bed, the days of hospitalization and the incidence of complications (P0.05). The I flow rate in the GDT group was less than that of the CVP group (P0.05) on the third day of the operation, and the average day after the operation was lower than that of the CVP group (P0.01), but the average day was the highest. There was no statistical difference between the two groups of body temperature, heart rate and analgesia (P0.05). At the 3 day after operation, the WBC in group GDT was lower than that in group CVP, and the Hb in group GDT was higher than that in group CVP (P0.05) on the 5 day after operation. The APTT of group CVP in group CVP was longer than that in the GDT group, and the fibrinogen in the GDT group was higher than that of the group at the 7 day after the operation. The 3 days, 5 days and 7 days after the operation were lower than those of the group. 05) the AST of group GDT was also lower than that of group CVP (P0.05) on the 5 day after operation. There was no significant difference in the other laboratory indexes between the two groups (P0.05).
Conclusion compared with conventional liquid therapy, patients undergoing laparoscopic hepatectomy need less infusion of colloid fluid, better tissue microcirculation and oxygen supply, less liver function and coagulation, lighter effects of liver function, lower inflammatory response, early intestinal function recovery, advantages in short-term clinical prognosis and significantly reduced hospitalization costs.
The second part
Effect of target directed fluid therapy on stress response in patients undergoing laparoscopic liver resection
Objective to compare the effects of target directed fluid therapy and conventional fluid therapy on stress response in patients undergoing laparoscopic liver resection.
Methods 44 patients were selected from January 2012 to July 2013 in a hospital minimally invasive Center for laparoscopic hepatectomy. The specific grouping situation, anesthesia and operation process were detailed in the first part. Compared the total number of white blood cells and neutrophils in peripheral venous blood of the two groups before and after operation, and the details of IL-6, IL-10, TNF- A and so on. The changes of cytokine and acute reaction proteins such as HSP70, SAA and CRP, and the difference between two groups of cortisone, insulin, blood glucose and insulin resistance index (HI) and the occurrence of SIRS within 7 days after the operation were compared.
Results cortisone, insulin, blood glucose and HI were not statistically different between the two groups (P0.05). The cortisone level in group GDT 3 hours and 12 hours after operation was significantly lower than that in group CVP (P0.01). The blood glucose and insulin levels in group GDT were lower than those in group CVP (P0.05) after 12 hours after operation, 1 days after operation, 3 days after operation. HI in group GDT was lower than CVP group (P0.05) within 3 days after operation, among which 12 were smaller after operation. There were significant statistical differences between two time points and 3 days after operation (P0.01). The proportion of SIRS in 1 days after operation was the highest, the incidence of group GDT (42.86%) was lower than that of group CVP (73.91%), there was statistical difference between the two groups (P0.05), and there was no statistical difference between the two groups of the other time points. All cytokines and acute reactive protein among the two groups before the operation were neither. Statistical difference (P0.05). The IL-6 level in group GDT was lower than that in group CVP (P0.05) 12 hours after operation, 3 days after operation, and in group GDT, 5 days after operation, and 7 days in group GDT, significantly lower than that between CVP group (P0.01).GDT group and CVP group. Except for 5 days after operation, the level of GDT group at all other time points after operation was higher than that of 12 group. 12 small after operation. At 1 days, 3 days and 7 days after operation, the level of TNF- alpha in group GDT was lower than that of group CVP (P0.05).GDT group 12 hours after operation, 1 days after operation, HSP70 level in 3 days after operation was lower than that of group CVP (P0.05). The SAA level of group GDT within 3 days after operation was lower than that of CVP group (P0.05), and 12 hours after operation and 1 days after operation were lower than that of the group.
Conclusion compared with conventional liquid therapy, GDT liquid therapy can reduce the level of stress related hormones and insulin resistance in patients with laparoscopic hepatectomy, and to some extent reduce the level of postoperative inflammatory cytokines and acute phase reaction protein, and reduce the incidence of postoperative SIRS hair growth, indicating that GDT liquid therapy helps to reduce the postoperative pathogenesis. The degree of inflammation and stress of the body accelerate the recovery of the body from stress.
The third part
Effect of target directed fluid therapy on immune function in patients undergoing laparoscopic liver resection
Objective to compare the effects of target directed fluid therapy and conventional fluid therapy on the immune function of patients undergoing laparoscopic liver resection.
Methods 44 patients undergoing laparoscopic hepatectomy from January 2012 to July 2013 were selected in a minimally invasive center of a hospital. The specific grouping, anesthesia and operation process were detailed in the first part. The T lymphocyte CD3, CD4, CD8, and monocyte CD14, HLA-DR expression level, NK cells were compared in groups of peripheral venous blood at 1,3,5,7 days after operation. Proportions and levels of IgA, IgM, IgG, C3 and C4.
Results there was no significant difference in CD3+T lymphocyte expression at each time point between group GDT and group CVP (P0.05), there was no significant difference in the expression of CD4+T lymphocyte, the proportion of CD4+/CD8+T lymphocyte and the proportion of NK cells in.GDT and CVP groups. The expression of CD4+T lymphocyte in GDT group and the proportion of CD4+/CD8+T lymphocytes at each time point after operation. The ratio of NK lymphocyte in group GDT was higher than that of group CVP (P0.05) at 5 days after operation, and the ratio of NK lymphocyte in group GDT was higher than that in group CVP (P0.05). The expression of CD14+/HLA-DR+ in group GDT was higher than that of group CVP (P0.05) 3 days, 5 days after operation (P0.05).GDT group compared with CVP group. In group CVP (P0.05), the expressions of IgM and IgG in group GDT were higher than those in group CVP (P0.05) 1 days after operation and 3 days after operation. The C4 level in GDT group was higher than that in CVP group on 1 days after operation (P0.05).
Conclusion the early postoperative manifestation of laparoscopic hepatectomy is mild immunosuppressive state. In the early post operation, the immunoglobulin level and immunoglobulin level in the early GDT group were higher than that in the CVP group, and the immunoglobulin consumption was less. It suggested that the cell immune function recovery in the GDT group was faster and earlier than the CVP group, and the immune function of the body fluid was less, GDT liquid treatment was less. Compared with the traditional fluid therapy strategy, the strategy has better protective effect on postoperative immune function.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R657.3

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